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What are the major challenges related to implementation of Baby Friendly Hospital Initiative (BFHI) in rural Australian hospitals?
The Baby Friendly Hospital initiative (BFHI) with its ten steps is considered attainable and its benefits are firmly accepted globally (Hannula et al., 2008, Rosenberg et al., 2008, WHO/UNICEF, 2009, Caldeira and Goncalves, 2007). To become Baby Friendly, a hospital or a birthing centre requires strong and supportive leadership and strategic planning (Merewood and Philipp, 2001). Besides these; the study hypothesis is that, there are likely to be challenges or barriers that influence the implementation of this global initiative, locally. The primary aim of this research is to explore and identify the major challenges or barriers related to accreditation process of BFHI in two Australian rural hospitals, in orders that policy makers or manager can formulate effective strategies to support to accreditation as a BFHI service and maintain the designation. The secondary aim of this research is to examine current status of infant feeding at Baby Friendly and Non-Baby Friendly hospitals in rural settings of a developed country as much of the literatures focuses of less developed or poor settings.
Breastfeeding is uniquely superior, widely accepted and most complete form of nutrition (Dòrea, 2009, American Academy of Pediatrics, 2005, Waller, 1952, WHO/UNICEF, 2009). There are many positive health outcomes for both infant and mother associated with breastfeeding. For example it is known that breastfed babies have reduced risk of lower respiratory tract infection (Gdalevich et al., 2001, Oddy et al., 2003), and may be protective against obesity (Armstrong and Reilly, 2002, Cope and Allison, 2008). On the other hand mothers who breastfeed have a decreased risk of ovarian and breast cancer (Danforth et al., 2007, Jernstrom et al., 2004, Yang and Jacobsen, 2008). In addition to this breastfeeding has an economic, social and environmental benefit (American Academy of Pediatrics, 2005). Understanding the benefits, WHO recommended that infant should start breastfeeding within one hour of life to be exclusively breastfed for six months, with timely initiation of adequate, safe and properly fed complementary foods at this point while continuing breastfeeding for up to two years of age or beyond (Australian College of Midwives Inc, 2009, National Health and Medical Research Council, 2003, Dyson et al., 2009, Dykes, 2005, WHO/UNICEF, 2009). Despite these recommendations, parents/mothers over the world are introducing formula to feed their newborn babies as a substitute of breast milk, which is said to have various adverse health impacts on the infant.
To protect, promote and support breastfeeding globally the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) in 1991 jointly introduced the Baby-Friendly Hospital Initiative (BFHI). Since then, approximately 20,000 hospitals throughout the world have received Baby-Friendly designation (WHO/UNICEF, 2009).To achieve a Baby-Friendly designation, the hospital or birthing centre must meet specific criteria and provide an optimal environment for the promotion, protection and support for breastfeeding as defined by the Ten Steps to successful breastfeeding (See Table -1) (WHO/UNICEF, 2009). Following the implementation of the Ten Steps in hospitals or birthing centre, the rate and duration of breastfeeding has been found to have increased worldwide (Sonia Bechara et al., 2005, Caldeira and Goncalves, 2007, Hofvander, 2005).
Table 1: Ten Steps to Successful Breastfeeding:
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practise rooming-in - allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
D. Rationale For The Study:
Breastfeeding rates in Australia are not improving and indeed seem to be falling. On average only 32 per cent of Australian babies were being breastfed exclusively at the age of six months (Australian Bureau of Statistics, 2003), which is less than the world average of 38 percent (UNICEF, 2008). This indicates that exclusive breastfeeding rates across Australia are far from the recommended guidelines, with an increasing proportion of infants being fed solids or formula prior to six month of age (Australian Bureau of Statistics, 2003). In Australia, the National Health and Medical Research Council (NHRMC) recommend exclusive breastfeeding for around 6 months. Similarly, NHMRC dietary guidelines also recommend an initiation rate of breastfeeding at birth 90% with 80% of infants being breastfed at the age of six months, as important objectives for Australia (National Health and Medical Research Council, 2003). In contrast only 48 percent of all children were being breastfeed in Australia, which is nearly less than half of the national target (Australian Bureau of Statistics, 2003).
In this situation the implementation of the Baby Friendly Hospital Initiative (BFHI) may be the best approach to protect, promote and support breastfeeding in Australia. The history of BFHI in Australia indicates that, it was initiated early in 1992 with the setting up of a Task Force to investigate the feasibility of BFHI implementation. The Australian College of Midwives has been given the responsibility for managing accreditation. Between the period of 1992-1997, Wangaratta and District Base Hospital in Victoria was the first rural Australian hospital accredited as Baby Friendly in 1997, alongside formal implementation of BFHI in Australia (Minchin, 2001). The Australian College of Midwives is the sole governing body of BFHI in Australia in collaboration with a National Advisory Council (NAC). Since that time 66 out of 317 maternity hospitals and birthing centers within the country have become accredited as Baby Friendly (Australian College of Midwives Inc, 2009). Uptake of BFHI implementation in Australia seems slow. Similarly, there are only 9 out of 90 health facilities accredited as Baby Friendly in New South Wales (Australian Inistitute of Health and Welfare, 1999, Australian College of Midwives Inc, 2009). Presuming a link between the benefits of breastfeeding and BFHI status, the rate of accreditation of health facilities seems is low. Thus the designed study will explore and identify barriers to BFHI implementation to support policy makers to formulate a strategy to assist accreditation across rural New South Wales. Similarly, this study will explore the infant feeding practice at BF and non BF Australian rural hospitals that will verify role of BFHI on improving infant feeding practices. The study area is the Far North Coast of the NSW. This area reflects the region of closely settled rural settings in Australia.
E. Objectives of Study:
To explore steps taken by four health services in rural NSW to achieve or not to seek BF accreditation.
To identify challenges/problems faced by health services on undertaking an accreditation process.
To study and compare infant feeding practices at two Baby Friendly and two Non-Baby Friendly Hospitals using mothers questionnaire.
To make recommendations for strategy development to advance BFHI status in NSW rural hospitals.
F.1. Study Design:
This will be a qualitative as well as a quantitative study. Semi structured in-depth interviews will be conducted among managers, child health nurses and midwives at maternity ward to collect information on challenges/problems faced by hospitals to achieve BF designation. A structured set of questionnaires for post-natal mothers will be used to gain information on infant feeding status within 4 hospitals to compare two hospitals with and two hospitals without Baby Friendly Hospital status.
F.2. Settings and Participants:
This study will be conducted at four Hospitals or Health Services where there are maternity services. Thus, four hospitals; including two BFHI accredited i.e. Mullumbimby and District War Memorial Hospital and Murwillumbah District Hospital and two non BFHI hospitals i.e. Lismore Base Hospital and Casino District Hospital in the Northern Rivers Region of NSW have been purposively selected for the study. Managers/Coordinators, Pediatricians/Child Health Nurse/Midwives at maternity ward and post-natal mothers at post-natal ward will be considered as the source of information. Semi-structured in-depth interview and structured questionnaire will be the tools for collection of required information.
F.3. Sample Size:
Four hospitals within the Northern Rivers Region of NSW will be selected purposely for this study. In total 6 in-depth interviews among following participants within the hospitals will be conducted.
Managers or Coordinators 4 (1 from each Health Services)
Child Health Nurses/Midwives 2 (1 from each BF accredited Health Services only)
Similarly, n=200 (Recruitment will aim at least 50 from each hospitals); structured questionnaires will be placed at the specified site of the post-natal ward with a request for mothers to fill in the questionnaire voluntarily before discharge and deposit them in a box designed for that purpose.
F.4. Data Collection and Analysis:
Both qualitative and quantitative methods of data collection will be used to gather the required information. Semi structured in-depth interviews and structured questionnaires will be used with participants. Interview guidelines and questionnaires have been developed based on the WHO/UNICEF Baby Friendly Hospital Initiative implementation guidelines. Digital recording will be used to record qualitative information generated at interview which will be transcribed by the researcher. Thematic analysis of transcribed data will be undertaken to explore/identify major challenges/problems regarding BFHI implementation accordingly.
Quantitative data will be analyzed using the statistical data analysis tool Epi Info.
G. Ethical Consideration:
There are no perceived risks to participants in this study. Confidentiality of information will be assured and informed consent will be obtained from the participants before in-depth interview. Similarly, mothers at post-natal ward will complete the questionnaires regarding infant feeding voluntarily and drop in to the box provided. Ethics approval from the Human Research Ethical Committee (HREC) of Southern Cross University and HREC of the North Coast Area Health Services will be obtained prior to data collection.
H. Dissemination Of Research Findings:
After analyzing the data obtained, a detailed research report will be prepared and submitted to examiners from the School of Health and Human Sciences, Southern Cross University. The researcher will endeavor to present the findings among interested and relevant professional groups.
Other than this it is very important to make findings available nationally and internationally for policy makers, medical practitioners, researchers and scholars interested in the subject. Thus, appropriate steps will be taken to publish research findings in internationally reputed journals e.g. The American Journal of Clinical Nutrition.